According to studies, surgical intervention can be delayed for a period of five days and replaced by conservative measures. However, this is also associated with an increased risk of morbidity and mortality (risk of illness and death):
- Surgery within 24 hours of hospital admission: mortality, 1.8%; major complications, 4%.
- Intervention after five days or even later: mortality, 6.1%; major complications, 15.4
The six risk factors according to Schwenter* can be used as a decision-making aid for surgery:
- Abdominal pain for more than 4 days
- Peritonism
- C-reactive protein > 7.5 mg/dl
- Leukocytes greater than 10,500 µl
- Greater than 500 ml of free fluid
- Reduced contrast agent uptake by the intestinal wall
* A point is assigned to each criterion present. If three or more of the criteria are positive, with a sensitivity (percentage of diseased patients in whom the disease is detected by the use of the test, i.e., a positive test result occurs) of almost 70% and a specificity (probability that actually healthy people who do not have the disease in question are also detected as healthy in the test) of more than 90%, there is a risk of strangulation and thus the need for surgery (level of evidence 2 A)
Absolute OP indication: complete mechanical obstruction (occlusion) and full-blown ileus disease
Relative OP indication: postoperative adhesions in case of multiple previous operations with incomplete passage obstruction, partial obstruction in case of known neoplasia (cancer)
Perioperative restrictive fluid management is required for patients with abdominal surgery! This is associated with faster recovery of gastrointestinal function and shorter hospital stay. Note: Over 70% of cases of small bowel obstruction can now be successfully treated conservatively. The key factor here is whether the bowel resumes function after placement of a gastric tube.
Mechanical ileus
Two forms of ileus have an absolute indication for surgery (immediate surgery):
- Strangulated ileus (to be operated within one hour!).
- Large bowel obstruction
1st order
- Adhesiolysis – loosening the adhesions.
- Removal of foreign bodies
- Tumor resection
- Partial bowel resection, if necessary with creation of a stoma (anus praeternaturalis – artificial intestinal outlet).
In 64% of cases, a purely laparoscopic procedure (laparoscopy) is possible for patients with small bowel ileus due to postoperative adhesions. This results in significantly lower morbidity (incidence of disease) and shorter length of hospital stay. In young patients without risk factors for anastomotic insufficiency (rupture or leakage of the new connection of the bowel ends), the method of choice is the single-stage surgical procedure without a stoma. Reasons to consider the creation of a stoma:
- Elderly and previously ill patient
- Inexperienced surgeon
- Dilated intestinal segment before stenosis
- Risk factors for anastomotic insufficiency.
- Pre-existing incontinence
- Perforation with peritonitis (inflammation of the peritoneum).
- Septic clinical picture (blood poisoning)
The perioperative lethality (mortality related to the total number of people with the disease) of an emergency laparotomy due to manifest ileus is 5-15%.
Functional ileus
1st order
- Eliminate the cause of functional ileus when it results from mechanical ileus.
- Creation of intestinal fistulas as ultima ratio.
Peritoneal carcinomatosis
Peritoneal carcinomatosis (extensive involvement of the peritoneum with malignant tumor cells) often leads to ileus symptoms. A computed tomography (CT) scan of the abdomen (abdominal CT) should be performed to estimate the extent of the tumor and clarify the cause of the ileus (mechanical versus functional ileus).If an absolute indication for surgery (ischemia, strangulation, perforation) has been ruled out and a mechanical ileus is unlikely, priority is given to drug therapy, and if necessary, interventional therapy (stenting for distal stenosis) or surgical therapy.
